Research findings and best practices in substance abuse treatment for offenders : a review of the literature

RESEARCH FINDINGS AND BEST PRACTICES IN
SUBSTANCE ABUSE TREATMENT FOR OFFENDERS
A Review of the Literature
Prepared for the NC DOC Substance Abuse Advisory Council
North Carolina Department of Correction
Office of Research and Planning
Sandy C. Pearce, Manager
Douglas Holbrook, Analyst
August 2002
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Treating Offenders with Alcohol and Other Drug Dependencies
The research literature and best practices literature uses a variety of terms to
refer to treatment for excessive alcohol and drug use: alcohol and other drug
dependency (AOD) treatment; chemical dependency treatment; substance abuse
treatment. In this review, the terms are used as the researchers/authors
reference them.
The purpose of substance abuse treatment for offenders is to stop the alcohol
and/or other drug abuse and to return the individual to productive functioning in
the family, workplace, and community. Measures of effectiveness typically
include levels of alcohol and/or other drug use, criminal behavior, family
functioning, employability, and medical conditions (NIDA, 1999). This report
provides a summary of the research literature on offender substance abuse
programs and a description of best practices literature.
Risk, Needs and Responsivity
Andrews, Bonta, and Hoge (1990) describe a science-based correctional model
for assessing and intervening with alcohol and other drug dependencies that
uses the assessment of the individual to drive the treatment plan. This model is
founded on the principles of risk, needs and responsivity. The “risk principle”
states that the most costly and intensive resources should be reserved for the
highest-risk cases. High-risk offenders have more to gain from treatment in
terms of reducing their risk for future involvement in crime. The “need principle”
states that future criminal activity can be reduced by identifying and intervening
with the criminogenic or crime-producing needs of the offender. Research
indicates that criminogenic needs include cognitive (thinking) distortions, deficits
in problem-solving ability, egocentricity, employability, substance abuse and
antisocial attitudes, sentiments and values. The “responsivity principle” refers to
offender characteristics that influence the offender’s individual response to
treatment. Examples of responsivity factors include the following: learning style,
personality characteristics, and treatment motivation. Research indicates that
addressing these three areas with offenders, through assessment and individual
treatment planning, can reduce recidivism (Andrews, 1995).
Screening, Assessment, and Treatment Planning
To provide effective services to offenders, treatment providers must understand
the special characteristics of this population. Alcohol and other drug-involved
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(AOD) offenders are not a homogenous group. These differences include
personality, patterns of AOD abuse, health status, socialization, education,
family, job training, urban and rural influences, and mental functioning. They
range from seriously antisocial individuals to those who are more pro-social and
have family and community support systems. Therefore it is critical to screen and
assess offenders prior to placing them in treatment programs. This screening
and assessment should determine the range of services needed by the offender
to learn to cope in society and should assist in developing an individualized case
plan (CSAT, 1995).
Screening and assessment is a multi-stage process. Screening is the initial
activity that identifies offenders who are likely to have AOD problems. Many
screening and tools exist to gauge an inmate’s need for treatment services.
Research indicates that inmates with substance abuse problems are at higher
risk for a number of problems and conditions that, left unidentified and
unaddressed, can increase the probability of relapse and reincarceration.
Screening instruments recommended by researchers for criminal justice
populations include the Alcohol Dependence Scale and the Drug Use section of
the Addiction Severity Index, the Texas Christian University Drug Dependence
Screen, and the Simple Screening Instrument. They found these instruments to
be superior to the SMAST and the SASSI (Rounds-Bryant et al., 2000).
An assessment is a process that helps determine the extent of an individual’s
problem with alcohol and other drugs and the appropriate level of treatment.
Assessments should be biopsychosocial in nature and should address medical,
psychiatric, psychological, emotional, social, familial, nutritional, legal and
vocational areas to determine the levels of treatment intervention and services
that will be needed (CSAT,1995).
While AOD screening is generally a one-time event, an AOD assessment is an
on-going process. Commonly used assessment instruments include the
Offender Profile Index, which is used to determine the appropriate type of AOD
abuse treatment for the offender and the Addiction Severity Index, which is
probably the most widely used standardized diagnostic instrument in the field.
Assessment is repeated throughout treatment and throughout the offender’s
involvement in the criminal justice system. Changes in the offender’s severity of
addiction and in problems related to addiction, as well as new life problems and
crises, require modifications in the treatment plan (CSAT,1995).
CARF (2001), the Rehabilitation Accreditation Commission, promotes the quality,
value, and optimal outcomes of rehabilitative services, according to their mission
statement. The Commission develops and maintains standards that enable
rehabilitative programs to attain accreditation. These standards are “consensus”
standards from the involvement of providers, consumers, and purchasers of
services. Screening, assessment, and case planning are required components of
a criminal justice treatment program under CARF standards.
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CARF standards require screening and require that qualified personnel conduct
assessments. The assessor may draw information from the offender, family
members, peers, and other collateral sources. The assessment should include,
at a minimum, the following information on the offender:
1) age or developmental level
2) gender
3) sexual orientation
4) social preferences
5) cultural background
6) psychological characteristics
7) physical condition
8) spiritual beliefs
9) employment history
10) family history, and
11) history of abuse
Case Management
Case management is the process of linking offenders with needed services in the
treatment system, including services other than AOD treatment. Supplementary
services can include medical, dental, mental healthcare, housing, education, and
vocational training. Critical case management issues include identifying those
who have a specific responsibility for the offender and those who make treatment
decisions. Written agreement must be reached about the roles of involved
parties. Cross training and memoranda of agreement between treatment
providers and other providers is essential. There are various case management
models – case management provided by the justice system, case management
provided by the treatment system, case management provided by a separate
entity from the treatment or justice systems, and case management provided by
multidisciplinary groups in the criminal justice system for offender management
(CSAT, 1995).
The Treatment Accountability for Safer Communities (TASC) Program is a
national model for case management. Case management in substance abuse as
the process that links individuals in treatment with ancillary community services.
It is often viewed as an adjunct to primary treatment and as an enhancement to
treatment. Enhancements often include eliminating barriers to treatment
participation, expanding access to complementary social services, making
referrals and coordinating the services obtained, monitoring progress, adjusting
plans as required, and serving as an advocate. TASC programs usually provide
all of these elements of case management. TASC case management provides
structured linkages between the criminal justice system and the treatment
system. This structure is defined by ten critical elements and is programmatically
measured by performance standards associated with each element. Over 40
local program evaluations of TASC took place between 1972 and 1982 and most
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found TASC effective in linking the criminal justice and treatment systems (Cook,
1992).
Treatment Modality Definitions and Examples
There are two primary theories for treating substance abuse. One is the disease
/medical model and the other is the social learning model. Substance abuse
treatment programs are usually based on one of these two models, though some
programs combine elements of the models. The disease theory describes
alcohol and/or drug addiction as a chronic, primary illness. It is viewed as a no-fault
three-part disease: physical, mental and spiritual. The focus is on teaching
alcoholics and addicts how to live with the condition for a lifetime through
abstinence, with the help of the 12 steps of Alcoholics Anonymous (Spicer,
1993).
Social learning theory describes addiction as learned maladapative behavior that
can be treated by teaching and modeling prosocial behavior. This view holds
that offenders learn antisocial thoughts and actions as a means of coping with
life. These behaviors are maintained by strong internal reinforcers such as
feelings of excitement, pleasure, and power offering immediate gratification
which is a stronger controlling force than the delayed negative consequences.
This theory stresses modifying the individual’s behavioral coping skills and
cognitive processes to improve the individual’s ability to function in the social
environment. Treatments based on this model include reducing the availability of
substances through restricted access, interdiction, and treatment (Parks et al.,
1999).
Treatment programs for offenders vary in terms of setting, length of stay,
intensity, modality, and treatment theory of behavior. There are many program
models such as outpatient methadone maintenance, short-term inpatient
Minnesota Model, therapeutic communities, cognitive behavioral interventions,
relapse prevention, and reality therapy. The three most common programmatic
models for substance abuse treatment for offenders are the Minnesota model
(also referred to as 12-step), therapeutic community, and cognitive behavior
therapy (Rounds-Bryant, 2000).
The Minnesota model, based on the disease theory, is popular nationally, and is
widely used, both in and out of prison. It is based on the 12 steps and 12
traditions of Alcoholics Anonymous (AA). The program’s goal is for recovering
individuals to abstain completely from using any substances (Rounds-Bryant et
al, 2000).
The Minnesota model is delivered in a formal setting and contains the following
elements: multidisciplinary treatment team, a therapeutic community milieu, small
group therapy, psycho-education, and aftercare. Although this model is
traditionally a self-help approach with non-professional, recovering addicts as
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group leaders, it can be facilitated and delivered as a formal, curriculum-based
treatment component. The model can draw on other models as needed to
facilitate the recovery of the addict. No evaluations of this model in a prison
setting were found (Spicer, 1993).
Cognitive behavior therapy, based on social learning theory, assumes that
substance abuse is a learned, maladaptive behavior pattern that can be changed
by training and practicing appropriate skills. The counselor presents didactic
information and coaches the offender to acquire new skills. This group-based
therapy is usually intensive and short-term, typically less than three months.
During this period, participants work in the group to learn better thinking and
behavioral approaches that reduce both alcohol and other drug dependence and
other antisocial behaviors (Rounds-Bryant, et al, 2000). Most cognitive behavior
programs require ongoing practice, and frequently encourage graduates to
participate in AA or NA as an adjunct to their treatment. The actual delivery of
the curriculum is a combination of instruction, practice within group, and
homework. The sessions are highly directive. This type of curriculum can be
offered as a component of a therapeutic community or a 12 step program. One
type of CBT programs is Moral Reconation Therapy (MRT), which focuses on
moral reasoning and development. MRT has been demonstrated to be effective
in reducing recidivism in Washington state (MacKenzie, 1998).
Therapeutic communities (TC) are residential programs with a stay ranging from
15 to 24 months; modified TCs last from 6 to 12 months. The therapeutic
community model focuses on global rehabilitation in which alcohol and other drug
(AOD) treatment is incorporated. The TC views AOD abuse and other problems
as reflections of chronic deficits in social, educational, vocational, familial,
economic, and personality development. The principle aim of a TC is global life-style
change; including abstinence from AODs, elimination of antisocial behavior,
enhanced education, constructive employment, and development of pro-social
attitudes and values. A TC frequently includes AA or other 12-step groups as a
tool to recovery. All TCs include the following elements: community structure,
hierarchy, and confrontation in order to rehabilitate clients (CSAT, 1995).
Moderation or abstinence is a controversial issue in the treatment of substance
abusers. Lightfoot (1999) describes the debate between the disease model
proponents, who believe that alcohol and other drug addiction is a progressive
disease which requires a commitment to lifelong abstinence, and the controlled
drinking proponents, who believe that moderate drinking is feasible for some
substance abusers. Research conducted in 1984 and 1987 demonstrates that
young single males are more likely to comply with moderation goals than
abstinence. Controlled drinking is usually defined as some limit on amount and
frequency of consumption, and drinking that does not result in physical
dependence, or social, legal, or health problems (Sanchez-Craig et.al, 1984,
1987). This research has led some to adopt harm reduction versus abstinence
as a treatment goal. Marlatt’s (2001) clinical work with adolescent and young
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adults who binge drink found that these youth were not ready to admit the extent
of their problem or to accept an abstinence-only goal. He asserts that a harm
reduction strategy in treating many problem drinkers is important if they are
otherwise unable or unwilling to pursue the abstinence goal.
Research Findings on AOD Treatment Outcomes
Program evaluations and meta-analyses of substance abuse treatment programs
indicate that while treatment can be effective, not all programs are effective.
Reviews of the effectiveness of substance abuse treatment consistently conclude
that there is no “magic bullet.” In other words, no single treatment
is effective for all persons with an alcohol or other drug disorder. Some data
indicates that providing more treatment than needed may reduce treatment
effectiveness; some data indicates that clients with more severe problems do
better in residential treatment (Lightfoot, 1999).
Rounds-Bryant et al., (2000) indicated that one of the strongest, most
consistently replicated findings of treatment effectiveness is the importance of
longer stays in treatment. Program effectiveness also varies based on program
characteristics, program completion, aftercare completion, and length of stay.
Recent research consistently shows that superior outcomes are found when
offenders complete all phases of treatment, including aftercare.
Anglin and (1990) found that different treatment modalities yield different results
with offender populations. Therapeutic communities have the best results
generally in reducing drug use and criminal recidivism, and methadone
maintenance programs show some positive effect. All programs’ outcomes are
improved by longer durations. A 1979 study by Simpson found that six months of
treatment in a therapeutic community or an outpatient program had significantly
better outcomes than methadone maintenance for the same duration.
Duration of participation has been shown to be a more important factor in
treatment success than voluntary participation. Several studies have shown that
the effectiveness of the treatment does not differ between offenders who enter
programs voluntarily and those who are ordered to participate (Anglin and Hser,
1990; Anglin and Maugh, 1992; Falkin, Wexler, and Lipton, 1990).
MacKenzie (1998) reviewed of literature on effectiveness of correctional
treatment programs and grouped them into three categories: what works, what
doesn’t work, and what we don’t know. According to this review, programs that
combine in-prison therapeutic communities with post-release aftercare are most
effective. Conversely, programs based on referral, monitoring, and case
management in the community, such as TASC without intensive TC while
incarcerated, do not reduce drug use or recidivism. There is not enough
research on community-based outpatient programs without in-prison treatment to
draw any conclusions.
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Lightfoot (1999) and Pelissier et al., (2000) note that outcome evaluations of
alcohol and drug programs have suffered from design problems. These problems
include selection bias of treatment participants, lack of appropriate comparison or
control groups, retrospective rather than prospective study designs, inadequate
baseline data, inadequate outcome measures, and insufficient follow-up periods.
Since field research is unlikely to ever be implemented ideally, researchers have
to address the methodological problems of the past to improve estimates of the
impact of treatment.
Prison-Based Treatment
In 1996 Lipton published a report that described evaluations of model drug
treatment programs for inmates in prison and jail. His review focused on the
therapeutic community (TC) model in which inmates were within a year of their
release date and the treatment lasted 9-12 months with a strong aftercare
component. He reported outcomes for Amity Right Turn (California, 1994),
Stay’n Out for males (New York, 1977-1984), Stay’n Out for Females (New York,
1977-1984), Cornerstone (Oregon,1984), Wharton (New Jersey, 1980), In-Prison
Therapeutic Community (Texas, 1990), Key-Crest (Delaware, 1995), and the
Bureau of Prisons (Federal, 1995). Most of the evaluations indicated lower
reincarceration or rearrest rates for the treatment group versus the comparison
group.
Two later evaluations were conducted on programs in Lipton’s original report. In
1999, Butzin, et al., studied the CREST Outreach Center in Delaware, a six-month
residential community-based therapeutic community for prison inmates
with histories of substance abuse. It serves males and females and has been
operating since the early 1990’s. It was the nation’s first combined therapeutic
community and work release facility. In an evaluation to examine the habilitation
effects of the program, the researchers compared outcomes such as recidivism,
drug use, and employment of CREST residents with a comparison group of drug-involved
inmates who entered Delaware’s traditional work release program. In
this 1999 study, the same researchers found that the recidivism rate (any arrest)
during an 18-month prison release follow-up was significantly lower for the
CREST completers (30%) than for the CREST non-completers (52%) and for the
comparison group (57%). Sixty one percent of the CREST completers
experienced relapse, 73% of the CREST non-completers experienced relapse,
and 85% of the comparison group experienced relapse. Offenders who
completed CREST had a statistically significant higher average income for the
previous year than the comparison group.
In 1997 Simpson and Knight, with Texas Christian University’s Institute of
Behavior Research, examined Texas in-prison therapeutic community treatment.
In a 12-month after prison release follow-up, they found that TC/Aftercare
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completers had a lower rearrest rate (18%) than did TC/Aftercare non-completers
(29%) and the Untreated Comparison Group (33%).
Between 1992 and 1997 Wexler conducted outcome evaluations of the Richard
J. Donavan Correctional Facility Substance Abuse Program in California. The
program is a 9-12 month 200 bed modified therapeutic community substance
abuse program. The experimental designed study involved 715 male volunteers
for the program who were randomly assigned to the treatment and control
groups. The study groups included a control group, a program drop group, a
prison treatment only group, a community drop group, and a community program
completer group. The data shows that return-to-custody rates 24 months after
release were lower for groups spending a longer time in treatment; 67% for the
control group, 56% for program dropouts, 49% for prison treatment only, 60% for
continuing care dropouts, and 14% for continuing care completers . At 36-
months post-parole, there was little difference between the groups on return-to-custody,
except for the Continuing Care Completer Group (California Department
of Corrections, 1999).
The Forever Free Program at the California Institution for Women was evaluated
in 1999 by Lowe. Forever Free is a 4 month intensive residential program which
uses a multi-dimensional treatment approach including behavioral change, the
12-steps, relapse prevention and a focus on women-specific topics. Lowe
studied inmates who exited the program during 1995 and 1996. The analysis
showed that 24 months post-parole, 60% of the program drops had returned to
prison, 55% of the in-prison treatment only group returned, and 48% of the in-prison
and continuing care in the community group returned to prison (California
Department of Corrections, 1999).
Lightfoot and Hodgins (1993) developed a typology of substance-abusing
offenders based on an extensive review of the literature. They identified the
following typologies based on severity and substance type: nonabusers , drug
abusers, alcohol abusers, emotionally distressed polysubstance abusers, and
organically impaired alcohol and drug abusers. Using these typologies as a is
risk continuum, in 1992 the Correctional Service of Canada introduced a model
to identify and treat substance abuse; the model has five components which are
designed to address the offender’s treatment needs from entry into prison to
release from supervision in the community. Offenders are screened using the
Computerized Lifestyle Assessment Instrument, an introductory education
module is provided to all new offenders, and they participate with their case
manager to determine the most appropriate treatment based on risks and needs.
Offenders with no-to-low levels of substance abuse problems or who were
involved in the sale and distribution of drugs are referred to nine 6-hour sessions
as part of the Alcohol, Drugs and Personal Choice program. Offenders with low-to-
moderate problems are referred to CHOICES, a brief treatment program with
three-month follow-up. Those with moderate-to-high problems are referred to the
more intensive Offender Substance Abuse Prerelease program; follow up and
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support are provided after the completion of treatment participation in
maintenance groups, which are available both in the institution and the
community.
The Offender Substance Abuse Prerelease program serves offenders within one
year of release. They participate in 26 half-day group sessions and three
individual counseling sessions. The modules are alcohol and drug education,
self-management training, social skills training, substance use and work, leisure
and lifestyle, and prerelease planning. Lightfoot (1999) conducted a 15-month
followup of 324 participants in the Offender Substance Abuse Prerelease
Program in 1994. More than 90% of offenders who completed the program were
released, and 30.2% who were released were reincarcerated within the 15-month
follow-up period. Rates of reincarceration varied directly as a function of
substance abuse severity level, more severe substance abusers were more likely
to be readmitted to prison. In addition, readmission rates were directly related to
the number of pre-post measures on which offenders showed improvement. Only
19% of offenders who improved on pre- and posttest measures were readmitted,
while 36% of those who showed no improvement were readmitted, as
demonstrated by survival analysis.
The Federal Bureau of Prisons operates a three-phase residential program which
has been shown to be effective in a 2000 evaluation study by Pelissier, et al.,
(2000). This program is based on the biopsychosocial model of treatment that
recognizes the complex interrelationships between psychological, biological, and
social variables.
The inmates receive nine months of treatment in a drug abuse treatment unit, a
transitional period, up to a year, in the general population with relapse prevention
planning and review of treatment techniques, and a required community
transition period following release into a community halfway house. The
treatment has a standardized curriculum comprised of modules including
screening and assessment, treatment orientation, criminal lifestyle confrontation,
cognitive skills building, relapse prevention, interpersonal skill building, wellness,
and transitional programming. The main finding in the evaluation was that
offenders who completed the residential drug abuse treatment program, and had
been released to the community for three years, were less likely to be re-arrested
or to test positive for drug use than were similar inmates who did not participate
in the drug abuse treatment program. Of the male inmates who completed the
program, 44% were re-arrested or revoked with three years after release to
supervision in the community compared to 52% of the inmates who did not
receive such treatment. For women, 25% of those who completed the residential
program, were arrested or revoked with three years after release, compared to
30% of the untreated women. As far as drug use, 50% of men who completed
the program used drugs within 3 years following release while 59% of those who
did not receive treatment used drugs. Among female inmates, 355 who
completed the program used drugs with the 3 years after release and 43% of
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those who did not receive treatment used drugs. While the FBOP intervention
occurs near the end of incarceration, it demonstrates that length of time in
treatment and completion of treatment are critical factors in success in the
program.
Community Treatment Evaluations
Anglin et al., (1999) reviewed research on five Treatment Alternatives to Street
Crime (TASC) programs. TASC is a case management model implemented in
various forms since the early 1970’s to facilitate treatment for substance abusing
offenders in the community. TASC provide a bridge between criminal justice
agencies and community-based treatment programs through coordination of
services. TASC identifies, assesses, and refers substance abusers to
appropriate community treatment services as an alternative to or a supplement to
criminal justice sanctions. After referring offenders to treatment, TASC monitors
their progress and compliance, especially through drug testing. The courts treat
dropping out of treatment or other noncompliance as a violation of release or
probation. Early process evaluations of TASC programs were generally positive.
Researchers found that programs screened and identified large numbers of drug
users in the criminal justice system and served as an effective link between
criminal justice and treatment systems. There was also evidence that TASC
increased treatment retention. The Treatment Outcome Prospective Study
(TOPS) conducted by Hubbard et al. (1988) found that TASC clients remained in
treatment longer than non-TASC clients, and the length of stay resulted in a more
positive outcome on treatment. A more recent evaluation began in 1991 with
funding from the National Institute on Drug Abuse. The programs included in the
study conformed to the TASC model as represented in the Ten Critical Program
Elements and Performance Standards of the Bureau of Justice Assistance and
served a high risk population (e.g. crack cocaine users). Five programs were
selected for the study, two adult programs using a randomized design, two adult
programs using a quasi-experimental design, and one juvenile program using a
quasi-experimental design. TASC participants were followed up after six months
and interviewed about treatment services received, drug use and criminal
activities. Researchers also verified self-reported information through drug tests,
treatment records, and court records. The evaluation found favorable effects of
TASC programs on service delivery and offender’s drug use. Findings on
criminal recidivism were mixed and difficult to interpret; this may be due to the
intensive monitoring that these offenders received while in the program, similar to
evaluation results on Intensive Supervision Probation programs.
In and extensive review of the literature from 1980 to 1997, Lightfoot (1999)
reports on the evaluation of the Drug Abuse Reporting Program in 1982 by
Simpson and Sells. The study involved more than 4,000 subjects (nonoffenders
and offenders) involved in five different types of treatment including: methadone
maintenance, therapeutic community, out-patient treatment, out-patient
detoxification and intake only (no treatment). Clients with the greatest criminal
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involvement had the poorest outcomes. Methadone maintenance, therapeutic
community, and out-patient treatment did not differ significantly in outcomes, but
were more favorable than completing outpatient detoxification and intake only.
Specialized programs designed for offenders were likely to have better outcomes
than nonspecialized programs or generic substance abuse programs since
criminality is a significant factor that independently affects a treatment outcome.
Lightfoot (1999) reports that in 1989 Vito studied the Kentucky Substance Abuse
Program that provided self-help counseling sessions and referrals to appropriate
community agencies for probationers and parolees on a service contract with a
private provider. The nature and dose of treatment was not described. One-year
outcomes were compared for treatment graduates, treatment dropouts, and a
comparison group. Treatment graduates had significantly lower arrest and
conviction rates than the comparison group, but not a lower reincarceration rate.
Latessa made similar findings in a study of alcoholic probationers in the Ohio
STOP Program. In 1994 Moon and Latessa evaluated an outpatient drug
treatment program, the Chemical Offender Program for felony offenders. This
was a three phase program including education, a 12-step component, and a
drug testing component. Results indicated no differences in rates of arrest and
conviction for misdemeanor and felony offenses. The study was limited by small
samples and a short follow-up period.
Lightfoot (1999) reported on the 1993 study of the Multiple Offender Alcoholism
Program, a treatment program for violent criminal offenders by Funderbank,
MacKenzie, DeHaen, and Stefan. Outpatient treatment consisted of contingency
management, rewards for program attendance and participation, and frequent
drug tests. An individualized cognitive behavioral treatment plan was developed
and then implemented using behavioral counseling and contingency contracting.
Treatment goals included reducing alcohol-related problems such as social
functioning and employment and reducing alcohol-related criminal activity. A
quasi-experimental design to compare outcomes for a treatment group, a
national sample, and two independent control groups. The results indicated that
active treatment clients engaged in significantly fewer violent crimes (61%
decrease) and had improved employment and social functioning significantly
during program participation.
Lightfoot’s examination of research indicates that some programs, such as
therapeutic communities, advocate the use of peer counselors. However,
empirical studies in the general psychotherapy literature and the substance
abuse literature suggest that therapists who are judged more skilled and
competent by peers have the ability to form a therapeutic alliance. These
professionals tend to foster a better client outcome.
CHOICES is a brief (five sessions) treatment and relapse prevention program
developed in 1993 for parolees in the Canadian correctional system. CHOICES
was originally designed to be delivered to offenders released to the community
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on parole but it is also offered in minimum security prisons. It is delivered to low-to-
moderate substance severity offenders. Offenders are referred by their parole
offices for a structured interview and testing prior to admission. A novel aspect of
the CHOICES program is that parole officers are given training in program
delivery, and they function as co-facilitators for the treatment and maintenance
groups in the community. The program was developed around Miller’s dynamic
concept of motivation for changes. The modules consist of motivation to change,
the ABC learning model of addiction, relapse triggers, problem-solving
techniques, and cognitive coping skills. After they complete the five sessions,
offenders are required to attend weekly maintenance sessions for a minimum of
3 months. Preliminary evaluation results with a sample of 95 parolees indicated
that during a 12-month follow-up, recidivism rates are comparable to those seen
in more intensive treatment; 48% had no new convictions, suspensions, or
revocations (Lightfoot, 1999).
Project MATCH (1998) studied whether different types of alcoholics (not
necessarily offenders) respond differently to particular treatments. There were
1,726 patients recruited from treatment facilities across the country were divided
into an outpatient group (recruited directly from the community) and an aftercare
group (just completed an inpatient or intensive day hospital treatment.
Participants in both groups were interviewed and tested to assess 20 individual
characteristics. Participants were randomly assigned to one of three treatments:
12 Step Facilitation, Cognitive Behavior Therapy, and Motivational Enhancement
Therapy. In a 36-month follow-up, the three treatments were found to be about
equally effective in terms of reducing drinking. Participants averaged 25 drinking
days per month before treatment and decreased to six drinking days per month
after treatment; they reported less drug use, less experience of depression, and
their liver function improved. Four participant characteristics were related to
successful treatment matching: anger, psychiatric severity, anger, and support of
drinking (Project Match Research Group, 1998).
Faye Taxman (1998) presented a paper on the reduction of recidivism through a
seamless community system of care at a conference sponsored by the Office of
National Drug Control Policy. Taxman evaluated twelve jurisdictions that
participated in the High Intensity Drug Trafficking Area project (HIDTA), funded
by the Office of National Drug Control Policy. Based on this research, Taxman
advocates moving from an individual case management approach to a systemic
case management approach which focuses on resource development, social
action plans, policy formation, data collection, information management,
program evaluation, and quality assurance. This approach integrates traditional
case management functions within the roles and responsibilities of appropriate
treatment and criminal justice staff. Twelve jurisdictions participated in the
HIDTA project, with the purpose of developing a seamless system between
criminal justice and treatment agencies by providing a continuum of treatment
care for the target population, drug testing and monitoring, and implementing
graduated sanctions to increase compliance with treatment. The study showed
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that 72% of offenders completed the first phase of treatment and 62% continued
treatment in the second phase. The researchers found that 12% of the
offenders were arrested for new crimes during 9 months in the community. This
is a lower rate than expected based on the history of the clients.
In an article on substance abuse and restorative justice practices, Schwebel and
Zaslaw (2002) describes a cognitively based substance abuse program for
adolescents called Seven Challenges. This program, used both in the
community and institutional settings in Florida. The Seven Challenges Program
is philosophically compatible with restorative justice – helping young people to
examine their behavior and make good decisions. It is an experiential program
that uses cognitive behavioral activities such as role-playing, active discussion,
work books and, exercises relevant to young people. Ancillary treatment
includes social skill development, cognitive processing, anger management,
problem-solving techniques, and pre-vocational and vocational training. In a
study by Arizona State University researchers in 1999, Schwebel states that the
outcomes for the 83 males and females who participated in an intensive Seven
Challenges outpatient program were positive. There were statistically significant
reductions in drug use and criminal behavior and improvements in family
relationships.
Breaking the Cycle (Kennedy, 1999) is a project begun in 1996 with funding from
Office of National Drug Control Policy and the National Institute of Justice. There
are four sites: Birmingham, Alabama; Jacksonville, Florida; Tacoma,
Washington; and Eugene, Oregon. This initiative is a systemic intervention
strategy to identify, supervise and treat drug users in the criminal justice or
juvenile justice system. The Breaking the Cycle (BTC) model creates a system
of integrated testing, treatment and graduated responses, and supervision to
reduce drug use and recidivism in the offender population. The goal of the
program is to identify offenders at the point of arrest and begin treatment
services in jail that continue into the community, whether the offender is on
probation supervision or not. Treatment is provided based on clinical
assessments of problem severity. Drug treatment is paired with enforced
abstinence which is monitored through regular drug testing linked to specific
sanctions for continued drug use. The key components of BTC are early
intervention, judicial oversight, graduated sanctions, and collaboration between
justice and treatment agencies. The Urban Institute conducted a process
evaluation of the projects and an impact evaluation is under publication. A
preliminary report of Jacksonville’s BTC program found reductions in criminal
activity and drug use among drug-involved defendants based on surveys
conducted with felony defendants shortly after arrest and again nine months
later. The responses of a sample of BTC defendants were compared to a
sample of similar defendants arrested in the year before BTC was implemented
(Harrell, 2001).
15
Listwan et al., (2002) summarized the research on drug courts from the 1997
U.S. General Accounting Office (GAO) report. Drug courts developed in the
1990’s as an alternative to incarceration and a supplement to community
supervision. Today, almost every state in the United States has a drug court,
though they differ from jurisdiction to jurisdiction. Drug courts are judicially-based
interventions in which offenders are required to participate in substance abuse
treatment, drug testing, and in some cases comply with the conditions of
probation. A team approach is used to manage the offender’s case and frequent
court appearances are held so that the judge can assess progress and provide
rewards or sanctions based on treatment participation and compliance with court
requirements.
According to Listwan et al., (2002), the GAO report and other updated reviews of
the research conclude that drug courts are successful in reducing recidivism and
substance abuse. However, some studies have found that drug courts failed to
reduce recidivism. The conflict in these findings is likely due to the differences in
programs from one jurisdiction to another. It is difficult to determine which
components or combination of features of the drug court model are most
important for determining success. Generally, the research suggests that drug
courts have been moderately successful at reducing drug use and recidivism
among offenders participating in programs. However, since most drug courts
contract with available service providers, the evaluations do not provide
information on which treatment models are most effective.
Transition From Prison to the Community
Research previously discussed in this report indicates that treatment in prison is
less likely to have a long-term impact if treatment and aftercare in the community
do not follow it up for a substantial period of time. Fields (1998) notes that there
is research on institution pre-release models of treatment that work, and on
community treatment models that work, but too little research on the process of
successful transition form the institution to the community. The transition for
offenders who have been in treatment in prison to successful living in the
community is crucial and difficult.
Vaillant (1988) conducted a long term study of 100 hospital-treated heroin
addicts and 100 hospital-treated alcohol-dependent individuals. The two groups
were prospectively followed for 20 and 12 years respectively. The individuals in
the study were followed up every 18 months, and criminal and hospital records
were checked. Vaillant examined factors that contributed to relapse and freedom
from relapse. He found that relapse is usually the result of poorly patterned social
behavior and thus to avoid relapse, these individuals needed to alter their whole
pattern of living. For both groups, encountering one or more of the following –
community compulsory parole supervision, methadone maintenance, a substitute
dependence (e.g. meditation, compulsive gambling, overeating), new social
support relationships (e.g. employment, new marriage), and inspirational group
16
membership (e.g. fundamentalist religion, Alcoholics Anonymous) - appeared
associated with freedom from relapse. Long term structure in an addict’s life
when he or she is released to the community can interfere with drug-seeking
behavior and prevent relapse.
Fields (1998) describes a 1990 Oregon Department of Corrections project to
show the effects of a structured transition program from institution to community
treatment. Inmates are treated for 3-6 months in prison and then followed
intensively for 6-9 months in community treatment and supervision. Key program
elements include the following:
• Service providers “reach in” to the institution – Parole and drug treatment
services begin in prison several months before the release.
• Joint institutional/community-release planning – Prison staff developed
release plans with inmates, their parole officers, and drug treatment
coordinators.
• Intensive supervision – Once released, the offender is supervised on
intensive parole.
• Continuity of treatment – Group treatment is continued in the community,
often with members of the offender’s prison treatment group. Peer support
for abstinence and recovery is an important part of these groups.
• Careful management of incentives and sanctions – Offenders are offered
incentives for treatment participation in prison and in the community (e.g.
desirable housing, earn extra pass time, were provided special job skills
counseling). They lost privileges according to a graduated scale if they did
not cooperate in treatment. In the community, graduated sanctions were
applied as needed and incentives included assistance in housing,
employment, and other specialized services.
Outcome studies showed a drop in the arrest and conviction rates of participating
offenders during the year following treatment. There was also improvement in
employment and community adjustment.
Best Practices
National Institute on Drug Abuse
The National Institute on Drug Abuse (NIDA) compiled a booklet in 1999 that
outlines principles of effective treatment, both in the community and in the
institutional setting. This document is based on review of several studies and
meta-analyses. NIDA identified the following thirteen principles of effective
treatment:
1. There is no single treatment modality that is appropriate for everyone.
Treatment settings, interventions, and services should be matched to each
person's particular problems and needs.
2. Treatment needs to be readily available and accessible so that willing
persons can participate.
17
3. Effective treatment addresses the multiple needs of the individual, the drug
use and any associated medical, psychological, social, vocational, and legal
problems.
4. An individual's treatment and services plan must be assessed continually
and modified as necessary to ensure that the plan meets the person's
changing needs.
5. Remaining in treatment for an adequate period of time is critical for
treatment effectiveness. Research indicates that for most patients, the
threshold of significant improvement is reached at about 3 months in
treatment.
6. Counseling (individual and/or group) and other behavioral therapies are
critical components of effective treatment for addiction.
7. Medications are an important element of treatment for many patients, but
only when combined with counseling and other behavioral therapies. For
patients with mental disorders, both behavioral treatments and medications
can be critically important.
8. Addicted or drug-abusing individuals with coexisting mental disorders
should have both disorders treated in an integrated way. Offenders
presenting for either condition should be assessed and treated for the co-occurrence
of the other type of disorder.
9. Medical detoxification is only the first stage of addiction treatment and by
itself does little to change long-term drug use. This is also true for
abstinence.
10. Treatment does not need to be voluntary to be effective. Strong motivation
can facilitate the treatment process. Sanctions and enticements (family and
employment, for example) can increase treatment entry, retention, and the
success of drug treatment.
11. Possible drug use during treatment must be monitored continuously. The
monitoring of drug and alcohol use during treatment can help the patient
withstand urges to use drugs and also provide early evidence of drug use so
that the individual's treatment plan can be adjusted.
12. Treatment programs should assess for HIV/AIDS, hepatitis B and C,
tuberculosis and other infectious diseases, and provide counseling to help
patients modify or change high-risk behaviors.
13. Recovery from drug addiction can be a long-term process and frequently
requires multiple episodes of treatment. As with other chronic illnesses,
relapses to drug use can occur during or after successful treatment
episodes. Participation in self-help support programs during and following
treatment often is helpful in maintaining abstinence.
NIDA also published the following four findings specific to prison-based
treatment:
1) The therapeutic community model of treatment can be highly effective
in reducing drug use and recidivism.
2) Treatment participants should be segregated from the general prison
population to protect them from “prison culture.”
18
3) Treatment gains can be lost if inmates are returned to the general
population after treatment; this suggests that treatment, to be most
effective, should occur late in the incarceration.
4) Relapse and recidivism are significantly lower if inmates continue with
treatment in the community following release.
Etheridge, Rounds-Bryant, Hubbard Research
A research project by Etheridge and Hubbard, designed to collect outcome
measures for community-based treatment services, yielded a table of core
components and comprehensive services necessary for effective, holistic
treatment.
Substance Abuse Treatment:
Core Components and Comprehensive Services
Core Treatment Components Comprehensive Services
Intake processing/client assessment
Treatment plan
Abstinence-oriented counseling
Supportive group & individual
Counseling
Substance use/urine screening
Clinical & case management
Pharmacotherapy
Discharge plan
Aftercare/continuing care
Self-help/mutual help meetings
(AA/NA)
Medical Services
Mental health services
Housing
Transportation
Child care
Family services
Financial services
Legal services
HIV/AIDS risk services
Educational services
Vocational services
In an evaluation of North Carolina’s SARGE program, Rounds-Bryant, Etheridge,
and Hubbard cite several studies that demonstrate that superior outcomes are
achieved when inmates complete all phases of planned treatment, including
aftercare. They identified thirteen elements present in in-prison treatment
programs that effectively reduce recidivism:
• a comprehensive, intensive therapeutic approach aimed at the criminal and
substance using lifestyle rather than a focus on substance abuse alone
• programs having a clear and consistent treatment philosophy
• a program environment characterized by empathy and security
• a committed and qualified treatment staff
• clear and unambiguous rules of conduct
• the use of ex-addicts and ex-offenders as role models
• use of peer pressure and peer role models
• inclusion of self-help principles
• incorporation of relapse prevention
• aftercare/continuity of care during the post-release period
19
• adequate administrative support from correctional staff
• separation of treatment participants from general prison population
• a treatment model with an integrated evaluation component
Additionally, Rounds-Bryant, et al., offered guidelines for program development
based on these components:
• valid standardized assessments designed to identify multiple disorders that
are often present in incarcerated populations
• individualized treatment plans and treatment matching based on intensity
and service needs
• an array of treatment alternatives including cognitive-behavioral, social
learning, self-help, and therapeutic community approaches that address the
dual problems of substance abuse and criminal thinking and values
• random urine screening during treatment
• use of peer pressure and peer role models
High Intensity Drug Trafficking Study
Based on the results of a study of12 jurisdictions in the High Intensity Drug
Trafficking Area project, Taxman (1998) recommends 12 principles for effective
systems of treatment, supervision, and transition services in the community.
These principles are:
1. Recidivism reduction should be the goal of the criminal justice and treatment
system. This shared goal would bring the systems into alignment. It
requires each system to rethink operations and priorities and to jointly
reallocate resources.
2. Treatment and criminal justice system features must be policy driven. The
systems must develop integrated screening, placement, testing, monitoring,
and sanction policies. They must form a policy team to develop these joint
policies.
3. Treatment and criminal justice must function as a team. After policies are
developed, team members must put them into practice on an on-going daily
basis.
4. Use drug testing to manage offenders. Urinalysis allows for immediate
confirmation of an offender’s drug use. It is a tool for screening, treatment
matching and monitoring compliance. Joint policies on drug testing are
crucial.
5. Target offenders for treatment where treatment can “work.” Target high risk,
high need offenders, because treatment is more likely to have an effect on
this population and on crime
6. Use treatment matching practices. Use screening and assessment
information to make informed decisions about the type of offender who
should be placed in residential, intensive outpatient, and outpatient
programs. The American Society of Addiction Medicine (ASAM) has
developed a protocol for treatment placement.
20
7. Create a treatment process and extend the length of time in treatment.
Research affirms the importance of length of time in treatment for substance
abusers, with better results usually occurring from longer participation in
treatment programs. Add less intensive outpatient service to residential
services upon release.
8. Allow behavioral contracts to bind the offender, the treatment system and
the criminal justice system. A behavioral contract can specify the
expectations for the offender, treatment staff, and criminal justice staff. It is
an explicit set of expectations with rewards and sanctions for compliance.
9. Designate special agents for supervising offenders in treatment programs.
Train specialized probation officers to supervise offenders in treatment
programs. In order to have a close working relationship, both probation and
treatment staff need to be specialists.
10. Sanction non-compliant behavior. Use contingency management, token
economies, and behavior modification techniques to address compliance.
Use sanctions to hold offenders accountable under their behavioral contract.
11. Reward positive behavior. The criminal justice system does not often
acknowledge positive achievements made by offenders. Yet an incentive
system that is swift, certain, and progressive can increase positive behavior.
12. Focus on quality, not quantity. Don’t lose sight of the goal, to reduce
recidivism. Instead of trying to serve the maximum number of offenders, try
to serve fewer offenders better in order to produce intended outcomes.
Don’t provide cheap services if they don’t work, provide services that work,
even if they are more costly.
Taxman concludes by saying that effective treatment services are synonymous
with effective criminal justice services.
21
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1157.

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RESEARCH FINDINGS AND BEST PRACTICES IN
SUBSTANCE ABUSE TREATMENT FOR OFFENDERS
A Review of the Literature
Prepared for the NC DOC Substance Abuse Advisory Council
North Carolina Department of Correction
Office of Research and Planning
Sandy C. Pearce, Manager
Douglas Holbrook, Analyst
August 2002
2
Treating Offenders with Alcohol and Other Drug Dependencies
The research literature and best practices literature uses a variety of terms to
refer to treatment for excessive alcohol and drug use: alcohol and other drug
dependency (AOD) treatment; chemical dependency treatment; substance abuse
treatment. In this review, the terms are used as the researchers/authors
reference them.
The purpose of substance abuse treatment for offenders is to stop the alcohol
and/or other drug abuse and to return the individual to productive functioning in
the family, workplace, and community. Measures of effectiveness typically
include levels of alcohol and/or other drug use, criminal behavior, family
functioning, employability, and medical conditions (NIDA, 1999). This report
provides a summary of the research literature on offender substance abuse
programs and a description of best practices literature.
Risk, Needs and Responsivity
Andrews, Bonta, and Hoge (1990) describe a science-based correctional model
for assessing and intervening with alcohol and other drug dependencies that
uses the assessment of the individual to drive the treatment plan. This model is
founded on the principles of risk, needs and responsivity. The “risk principle”
states that the most costly and intensive resources should be reserved for the
highest-risk cases. High-risk offenders have more to gain from treatment in
terms of reducing their risk for future involvement in crime. The “need principle”
states that future criminal activity can be reduced by identifying and intervening
with the criminogenic or crime-producing needs of the offender. Research
indicates that criminogenic needs include cognitive (thinking) distortions, deficits
in problem-solving ability, egocentricity, employability, substance abuse and
antisocial attitudes, sentiments and values. The “responsivity principle” refers to
offender characteristics that influence the offender’s individual response to
treatment. Examples of responsivity factors include the following: learning style,
personality characteristics, and treatment motivation. Research indicates that
addressing these three areas with offenders, through assessment and individual
treatment planning, can reduce recidivism (Andrews, 1995).
Screening, Assessment, and Treatment Planning
To provide effective services to offenders, treatment providers must understand
the special characteristics of this population. Alcohol and other drug-involved
3
(AOD) offenders are not a homogenous group. These differences include
personality, patterns of AOD abuse, health status, socialization, education,
family, job training, urban and rural influences, and mental functioning. They
range from seriously antisocial individuals to those who are more pro-social and
have family and community support systems. Therefore it is critical to screen and
assess offenders prior to placing them in treatment programs. This screening
and assessment should determine the range of services needed by the offender
to learn to cope in society and should assist in developing an individualized case
plan (CSAT, 1995).
Screening and assessment is a multi-stage process. Screening is the initial
activity that identifies offenders who are likely to have AOD problems. Many
screening and tools exist to gauge an inmate’s need for treatment services.
Research indicates that inmates with substance abuse problems are at higher
risk for a number of problems and conditions that, left unidentified and
unaddressed, can increase the probability of relapse and reincarceration.
Screening instruments recommended by researchers for criminal justice
populations include the Alcohol Dependence Scale and the Drug Use section of
the Addiction Severity Index, the Texas Christian University Drug Dependence
Screen, and the Simple Screening Instrument. They found these instruments to
be superior to the SMAST and the SASSI (Rounds-Bryant et al., 2000).
An assessment is a process that helps determine the extent of an individual’s
problem with alcohol and other drugs and the appropriate level of treatment.
Assessments should be biopsychosocial in nature and should address medical,
psychiatric, psychological, emotional, social, familial, nutritional, legal and
vocational areas to determine the levels of treatment intervention and services
that will be needed (CSAT,1995).
While AOD screening is generally a one-time event, an AOD assessment is an
on-going process. Commonly used assessment instruments include the
Offender Profile Index, which is used to determine the appropriate type of AOD
abuse treatment for the offender and the Addiction Severity Index, which is
probably the most widely used standardized diagnostic instrument in the field.
Assessment is repeated throughout treatment and throughout the offender’s
involvement in the criminal justice system. Changes in the offender’s severity of
addiction and in problems related to addiction, as well as new life problems and
crises, require modifications in the treatment plan (CSAT,1995).
CARF (2001), the Rehabilitation Accreditation Commission, promotes the quality,
value, and optimal outcomes of rehabilitative services, according to their mission
statement. The Commission develops and maintains standards that enable
rehabilitative programs to attain accreditation. These standards are “consensus”
standards from the involvement of providers, consumers, and purchasers of
services. Screening, assessment, and case planning are required components of
a criminal justice treatment program under CARF standards.
4
CARF standards require screening and require that qualified personnel conduct
assessments. The assessor may draw information from the offender, family
members, peers, and other collateral sources. The assessment should include,
at a minimum, the following information on the offender:
1) age or developmental level
2) gender
3) sexual orientation
4) social preferences
5) cultural background
6) psychological characteristics
7) physical condition
8) spiritual beliefs
9) employment history
10) family history, and
11) history of abuse
Case Management
Case management is the process of linking offenders with needed services in the
treatment system, including services other than AOD treatment. Supplementary
services can include medical, dental, mental healthcare, housing, education, and
vocational training. Critical case management issues include identifying those
who have a specific responsibility for the offender and those who make treatment
decisions. Written agreement must be reached about the roles of involved
parties. Cross training and memoranda of agreement between treatment
providers and other providers is essential. There are various case management
models – case management provided by the justice system, case management
provided by the treatment system, case management provided by a separate
entity from the treatment or justice systems, and case management provided by
multidisciplinary groups in the criminal justice system for offender management
(CSAT, 1995).
The Treatment Accountability for Safer Communities (TASC) Program is a
national model for case management. Case management in substance abuse as
the process that links individuals in treatment with ancillary community services.
It is often viewed as an adjunct to primary treatment and as an enhancement to
treatment. Enhancements often include eliminating barriers to treatment
participation, expanding access to complementary social services, making
referrals and coordinating the services obtained, monitoring progress, adjusting
plans as required, and serving as an advocate. TASC programs usually provide
all of these elements of case management. TASC case management provides
structured linkages between the criminal justice system and the treatment
system. This structure is defined by ten critical elements and is programmatically
measured by performance standards associated with each element. Over 40
local program evaluations of TASC took place between 1972 and 1982 and most
5
found TASC effective in linking the criminal justice and treatment systems (Cook,
1992).
Treatment Modality Definitions and Examples
There are two primary theories for treating substance abuse. One is the disease
/medical model and the other is the social learning model. Substance abuse
treatment programs are usually based on one of these two models, though some
programs combine elements of the models. The disease theory describes
alcohol and/or drug addiction as a chronic, primary illness. It is viewed as a no-fault
three-part disease: physical, mental and spiritual. The focus is on teaching
alcoholics and addicts how to live with the condition for a lifetime through
abstinence, with the help of the 12 steps of Alcoholics Anonymous (Spicer,
1993).
Social learning theory describes addiction as learned maladapative behavior that
can be treated by teaching and modeling prosocial behavior. This view holds
that offenders learn antisocial thoughts and actions as a means of coping with
life. These behaviors are maintained by strong internal reinforcers such as
feelings of excitement, pleasure, and power offering immediate gratification
which is a stronger controlling force than the delayed negative consequences.
This theory stresses modifying the individual’s behavioral coping skills and
cognitive processes to improve the individual’s ability to function in the social
environment. Treatments based on this model include reducing the availability of
substances through restricted access, interdiction, and treatment (Parks et al.,
1999).
Treatment programs for offenders vary in terms of setting, length of stay,
intensity, modality, and treatment theory of behavior. There are many program
models such as outpatient methadone maintenance, short-term inpatient
Minnesota Model, therapeutic communities, cognitive behavioral interventions,
relapse prevention, and reality therapy. The three most common programmatic
models for substance abuse treatment for offenders are the Minnesota model
(also referred to as 12-step), therapeutic community, and cognitive behavior
therapy (Rounds-Bryant, 2000).
The Minnesota model, based on the disease theory, is popular nationally, and is
widely used, both in and out of prison. It is based on the 12 steps and 12
traditions of Alcoholics Anonymous (AA). The program’s goal is for recovering
individuals to abstain completely from using any substances (Rounds-Bryant et
al, 2000).
The Minnesota model is delivered in a formal setting and contains the following
elements: multidisciplinary treatment team, a therapeutic community milieu, small
group therapy, psycho-education, and aftercare. Although this model is
traditionally a self-help approach with non-professional, recovering addicts as
6
group leaders, it can be facilitated and delivered as a formal, curriculum-based
treatment component. The model can draw on other models as needed to
facilitate the recovery of the addict. No evaluations of this model in a prison
setting were found (Spicer, 1993).
Cognitive behavior therapy, based on social learning theory, assumes that
substance abuse is a learned, maladaptive behavior pattern that can be changed
by training and practicing appropriate skills. The counselor presents didactic
information and coaches the offender to acquire new skills. This group-based
therapy is usually intensive and short-term, typically less than three months.
During this period, participants work in the group to learn better thinking and
behavioral approaches that reduce both alcohol and other drug dependence and
other antisocial behaviors (Rounds-Bryant, et al, 2000). Most cognitive behavior
programs require ongoing practice, and frequently encourage graduates to
participate in AA or NA as an adjunct to their treatment. The actual delivery of
the curriculum is a combination of instruction, practice within group, and
homework. The sessions are highly directive. This type of curriculum can be
offered as a component of a therapeutic community or a 12 step program. One
type of CBT programs is Moral Reconation Therapy (MRT), which focuses on
moral reasoning and development. MRT has been demonstrated to be effective
in reducing recidivism in Washington state (MacKenzie, 1998).
Therapeutic communities (TC) are residential programs with a stay ranging from
15 to 24 months; modified TCs last from 6 to 12 months. The therapeutic
community model focuses on global rehabilitation in which alcohol and other drug
(AOD) treatment is incorporated. The TC views AOD abuse and other problems
as reflections of chronic deficits in social, educational, vocational, familial,
economic, and personality development. The principle aim of a TC is global life-style
change; including abstinence from AODs, elimination of antisocial behavior,
enhanced education, constructive employment, and development of pro-social
attitudes and values. A TC frequently includes AA or other 12-step groups as a
tool to recovery. All TCs include the following elements: community structure,
hierarchy, and confrontation in order to rehabilitate clients (CSAT, 1995).
Moderation or abstinence is a controversial issue in the treatment of substance
abusers. Lightfoot (1999) describes the debate between the disease model
proponents, who believe that alcohol and other drug addiction is a progressive
disease which requires a commitment to lifelong abstinence, and the controlled
drinking proponents, who believe that moderate drinking is feasible for some
substance abusers. Research conducted in 1984 and 1987 demonstrates that
young single males are more likely to comply with moderation goals than
abstinence. Controlled drinking is usually defined as some limit on amount and
frequency of consumption, and drinking that does not result in physical
dependence, or social, legal, or health problems (Sanchez-Craig et.al, 1984,
1987). This research has led some to adopt harm reduction versus abstinence
as a treatment goal. Marlatt’s (2001) clinical work with adolescent and young
7
adults who binge drink found that these youth were not ready to admit the extent
of their problem or to accept an abstinence-only goal. He asserts that a harm
reduction strategy in treating many problem drinkers is important if they are
otherwise unable or unwilling to pursue the abstinence goal.
Research Findings on AOD Treatment Outcomes
Program evaluations and meta-analyses of substance abuse treatment programs
indicate that while treatment can be effective, not all programs are effective.
Reviews of the effectiveness of substance abuse treatment consistently conclude
that there is no “magic bullet.” In other words, no single treatment
is effective for all persons with an alcohol or other drug disorder. Some data
indicates that providing more treatment than needed may reduce treatment
effectiveness; some data indicates that clients with more severe problems do
better in residential treatment (Lightfoot, 1999).
Rounds-Bryant et al., (2000) indicated that one of the strongest, most
consistently replicated findings of treatment effectiveness is the importance of
longer stays in treatment. Program effectiveness also varies based on program
characteristics, program completion, aftercare completion, and length of stay.
Recent research consistently shows that superior outcomes are found when
offenders complete all phases of treatment, including aftercare.
Anglin and (1990) found that different treatment modalities yield different results
with offender populations. Therapeutic communities have the best results
generally in reducing drug use and criminal recidivism, and methadone
maintenance programs show some positive effect. All programs’ outcomes are
improved by longer durations. A 1979 study by Simpson found that six months of
treatment in a therapeutic community or an outpatient program had significantly
better outcomes than methadone maintenance for the same duration.
Duration of participation has been shown to be a more important factor in
treatment success than voluntary participation. Several studies have shown that
the effectiveness of the treatment does not differ between offenders who enter
programs voluntarily and those who are ordered to participate (Anglin and Hser,
1990; Anglin and Maugh, 1992; Falkin, Wexler, and Lipton, 1990).
MacKenzie (1998) reviewed of literature on effectiveness of correctional
treatment programs and grouped them into three categories: what works, what
doesn’t work, and what we don’t know. According to this review, programs that
combine in-prison therapeutic communities with post-release aftercare are most
effective. Conversely, programs based on referral, monitoring, and case
management in the community, such as TASC without intensive TC while
incarcerated, do not reduce drug use or recidivism. There is not enough
research on community-based outpatient programs without in-prison treatment to
draw any conclusions.
8
Lightfoot (1999) and Pelissier et al., (2000) note that outcome evaluations of
alcohol and drug programs have suffered from design problems. These problems
include selection bias of treatment participants, lack of appropriate comparison or
control groups, retrospective rather than prospective study designs, inadequate
baseline data, inadequate outcome measures, and insufficient follow-up periods.
Since field research is unlikely to ever be implemented ideally, researchers have
to address the methodological problems of the past to improve estimates of the
impact of treatment.
Prison-Based Treatment
In 1996 Lipton published a report that described evaluations of model drug
treatment programs for inmates in prison and jail. His review focused on the
therapeutic community (TC) model in which inmates were within a year of their
release date and the treatment lasted 9-12 months with a strong aftercare
component. He reported outcomes for Amity Right Turn (California, 1994),
Stay’n Out for males (New York, 1977-1984), Stay’n Out for Females (New York,
1977-1984), Cornerstone (Oregon,1984), Wharton (New Jersey, 1980), In-Prison
Therapeutic Community (Texas, 1990), Key-Crest (Delaware, 1995), and the
Bureau of Prisons (Federal, 1995). Most of the evaluations indicated lower
reincarceration or rearrest rates for the treatment group versus the comparison
group.
Two later evaluations were conducted on programs in Lipton’s original report. In
1999, Butzin, et al., studied the CREST Outreach Center in Delaware, a six-month
residential community-based therapeutic community for prison inmates
with histories of substance abuse. It serves males and females and has been
operating since the early 1990’s. It was the nation’s first combined therapeutic
community and work release facility. In an evaluation to examine the habilitation
effects of the program, the researchers compared outcomes such as recidivism,
drug use, and employment of CREST residents with a comparison group of drug-involved
inmates who entered Delaware’s traditional work release program. In
this 1999 study, the same researchers found that the recidivism rate (any arrest)
during an 18-month prison release follow-up was significantly lower for the
CREST completers (30%) than for the CREST non-completers (52%) and for the
comparison group (57%). Sixty one percent of the CREST completers
experienced relapse, 73% of the CREST non-completers experienced relapse,
and 85% of the comparison group experienced relapse. Offenders who
completed CREST had a statistically significant higher average income for the
previous year than the comparison group.
In 1997 Simpson and Knight, with Texas Christian University’s Institute of
Behavior Research, examined Texas in-prison therapeutic community treatment.
In a 12-month after prison release follow-up, they found that TC/Aftercare
9
completers had a lower rearrest rate (18%) than did TC/Aftercare non-completers
(29%) and the Untreated Comparison Group (33%).
Between 1992 and 1997 Wexler conducted outcome evaluations of the Richard
J. Donavan Correctional Facility Substance Abuse Program in California. The
program is a 9-12 month 200 bed modified therapeutic community substance
abuse program. The experimental designed study involved 715 male volunteers
for the program who were randomly assigned to the treatment and control
groups. The study groups included a control group, a program drop group, a
prison treatment only group, a community drop group, and a community program
completer group. The data shows that return-to-custody rates 24 months after
release were lower for groups spending a longer time in treatment; 67% for the
control group, 56% for program dropouts, 49% for prison treatment only, 60% for
continuing care dropouts, and 14% for continuing care completers . At 36-
months post-parole, there was little difference between the groups on return-to-custody,
except for the Continuing Care Completer Group (California Department
of Corrections, 1999).
The Forever Free Program at the California Institution for Women was evaluated
in 1999 by Lowe. Forever Free is a 4 month intensive residential program which
uses a multi-dimensional treatment approach including behavioral change, the
12-steps, relapse prevention and a focus on women-specific topics. Lowe
studied inmates who exited the program during 1995 and 1996. The analysis
showed that 24 months post-parole, 60% of the program drops had returned to
prison, 55% of the in-prison treatment only group returned, and 48% of the in-prison
and continuing care in the community group returned to prison (California
Department of Corrections, 1999).
Lightfoot and Hodgins (1993) developed a typology of substance-abusing
offenders based on an extensive review of the literature. They identified the
following typologies based on severity and substance type: nonabusers , drug
abusers, alcohol abusers, emotionally distressed polysubstance abusers, and
organically impaired alcohol and drug abusers. Using these typologies as a is
risk continuum, in 1992 the Correctional Service of Canada introduced a model
to identify and treat substance abuse; the model has five components which are
designed to address the offender’s treatment needs from entry into prison to
release from supervision in the community. Offenders are screened using the
Computerized Lifestyle Assessment Instrument, an introductory education
module is provided to all new offenders, and they participate with their case
manager to determine the most appropriate treatment based on risks and needs.
Offenders with no-to-low levels of substance abuse problems or who were
involved in the sale and distribution of drugs are referred to nine 6-hour sessions
as part of the Alcohol, Drugs and Personal Choice program. Offenders with low-to-
moderate problems are referred to CHOICES, a brief treatment program with
three-month follow-up. Those with moderate-to-high problems are referred to the
more intensive Offender Substance Abuse Prerelease program; follow up and
10
support are provided after the completion of treatment participation in
maintenance groups, which are available both in the institution and the
community.
The Offender Substance Abuse Prerelease program serves offenders within one
year of release. They participate in 26 half-day group sessions and three
individual counseling sessions. The modules are alcohol and drug education,
self-management training, social skills training, substance use and work, leisure
and lifestyle, and prerelease planning. Lightfoot (1999) conducted a 15-month
followup of 324 participants in the Offender Substance Abuse Prerelease
Program in 1994. More than 90% of offenders who completed the program were
released, and 30.2% who were released were reincarcerated within the 15-month
follow-up period. Rates of reincarceration varied directly as a function of
substance abuse severity level, more severe substance abusers were more likely
to be readmitted to prison. In addition, readmission rates were directly related to
the number of pre-post measures on which offenders showed improvement. Only
19% of offenders who improved on pre- and posttest measures were readmitted,
while 36% of those who showed no improvement were readmitted, as
demonstrated by survival analysis.
The Federal Bureau of Prisons operates a three-phase residential program which
has been shown to be effective in a 2000 evaluation study by Pelissier, et al.,
(2000). This program is based on the biopsychosocial model of treatment that
recognizes the complex interrelationships between psychological, biological, and
social variables.
The inmates receive nine months of treatment in a drug abuse treatment unit, a
transitional period, up to a year, in the general population with relapse prevention
planning and review of treatment techniques, and a required community
transition period following release into a community halfway house. The
treatment has a standardized curriculum comprised of modules including
screening and assessment, treatment orientation, criminal lifestyle confrontation,
cognitive skills building, relapse prevention, interpersonal skill building, wellness,
and transitional programming. The main finding in the evaluation was that
offenders who completed the residential drug abuse treatment program, and had
been released to the community for three years, were less likely to be re-arrested
or to test positive for drug use than were similar inmates who did not participate
in the drug abuse treatment program. Of the male inmates who completed the
program, 44% were re-arrested or revoked with three years after release to
supervision in the community compared to 52% of the inmates who did not
receive such treatment. For women, 25% of those who completed the residential
program, were arrested or revoked with three years after release, compared to
30% of the untreated women. As far as drug use, 50% of men who completed
the program used drugs within 3 years following release while 59% of those who
did not receive treatment used drugs. Among female inmates, 355 who
completed the program used drugs with the 3 years after release and 43% of
11
those who did not receive treatment used drugs. While the FBOP intervention
occurs near the end of incarceration, it demonstrates that length of time in
treatment and completion of treatment are critical factors in success in the
program.
Community Treatment Evaluations
Anglin et al., (1999) reviewed research on five Treatment Alternatives to Street
Crime (TASC) programs. TASC is a case management model implemented in
various forms since the early 1970’s to facilitate treatment for substance abusing
offenders in the community. TASC provide a bridge between criminal justice
agencies and community-based treatment programs through coordination of
services. TASC identifies, assesses, and refers substance abusers to
appropriate community treatment services as an alternative to or a supplement to
criminal justice sanctions. After referring offenders to treatment, TASC monitors
their progress and compliance, especially through drug testing. The courts treat
dropping out of treatment or other noncompliance as a violation of release or
probation. Early process evaluations of TASC programs were generally positive.
Researchers found that programs screened and identified large numbers of drug
users in the criminal justice system and served as an effective link between
criminal justice and treatment systems. There was also evidence that TASC
increased treatment retention. The Treatment Outcome Prospective Study
(TOPS) conducted by Hubbard et al. (1988) found that TASC clients remained in
treatment longer than non-TASC clients, and the length of stay resulted in a more
positive outcome on treatment. A more recent evaluation began in 1991 with
funding from the National Institute on Drug Abuse. The programs included in the
study conformed to the TASC model as represented in the Ten Critical Program
Elements and Performance Standards of the Bureau of Justice Assistance and
served a high risk population (e.g. crack cocaine users). Five programs were
selected for the study, two adult programs using a randomized design, two adult
programs using a quasi-experimental design, and one juvenile program using a
quasi-experimental design. TASC participants were followed up after six months
and interviewed about treatment services received, drug use and criminal
activities. Researchers also verified self-reported information through drug tests,
treatment records, and court records. The evaluation found favorable effects of
TASC programs on service delivery and offender’s drug use. Findings on
criminal recidivism were mixed and difficult to interpret; this may be due to the
intensive monitoring that these offenders received while in the program, similar to
evaluation results on Intensive Supervision Probation programs.
In and extensive review of the literature from 1980 to 1997, Lightfoot (1999)
reports on the evaluation of the Drug Abuse Reporting Program in 1982 by
Simpson and Sells. The study involved more than 4,000 subjects (nonoffenders
and offenders) involved in five different types of treatment including: methadone
maintenance, therapeutic community, out-patient treatment, out-patient
detoxification and intake only (no treatment). Clients with the greatest criminal
12
involvement had the poorest outcomes. Methadone maintenance, therapeutic
community, and out-patient treatment did not differ significantly in outcomes, but
were more favorable than completing outpatient detoxification and intake only.
Specialized programs designed for offenders were likely to have better outcomes
than nonspecialized programs or generic substance abuse programs since
criminality is a significant factor that independently affects a treatment outcome.
Lightfoot (1999) reports that in 1989 Vito studied the Kentucky Substance Abuse
Program that provided self-help counseling sessions and referrals to appropriate
community agencies for probationers and parolees on a service contract with a
private provider. The nature and dose of treatment was not described. One-year
outcomes were compared for treatment graduates, treatment dropouts, and a
comparison group. Treatment graduates had significantly lower arrest and
conviction rates than the comparison group, but not a lower reincarceration rate.
Latessa made similar findings in a study of alcoholic probationers in the Ohio
STOP Program. In 1994 Moon and Latessa evaluated an outpatient drug
treatment program, the Chemical Offender Program for felony offenders. This
was a three phase program including education, a 12-step component, and a
drug testing component. Results indicated no differences in rates of arrest and
conviction for misdemeanor and felony offenses. The study was limited by small
samples and a short follow-up period.
Lightfoot (1999) reported on the 1993 study of the Multiple Offender Alcoholism
Program, a treatment program for violent criminal offenders by Funderbank,
MacKenzie, DeHaen, and Stefan. Outpatient treatment consisted of contingency
management, rewards for program attendance and participation, and frequent
drug tests. An individualized cognitive behavioral treatment plan was developed
and then implemented using behavioral counseling and contingency contracting.
Treatment goals included reducing alcohol-related problems such as social
functioning and employment and reducing alcohol-related criminal activity. A
quasi-experimental design to compare outcomes for a treatment group, a
national sample, and two independent control groups. The results indicated that
active treatment clients engaged in significantly fewer violent crimes (61%
decrease) and had improved employment and social functioning significantly
during program participation.
Lightfoot’s examination of research indicates that some programs, such as
therapeutic communities, advocate the use of peer counselors. However,
empirical studies in the general psychotherapy literature and the substance
abuse literature suggest that therapists who are judged more skilled and
competent by peers have the ability to form a therapeutic alliance. These
professionals tend to foster a better client outcome.
CHOICES is a brief (five sessions) treatment and relapse prevention program
developed in 1993 for parolees in the Canadian correctional system. CHOICES
was originally designed to be delivered to offenders released to the community
13
on parole but it is also offered in minimum security prisons. It is delivered to low-to-
moderate substance severity offenders. Offenders are referred by their parole
offices for a structured interview and testing prior to admission. A novel aspect of
the CHOICES program is that parole officers are given training in program
delivery, and they function as co-facilitators for the treatment and maintenance
groups in the community. The program was developed around Miller’s dynamic
concept of motivation for changes. The modules consist of motivation to change,
the ABC learning model of addiction, relapse triggers, problem-solving
techniques, and cognitive coping skills. After they complete the five sessions,
offenders are required to attend weekly maintenance sessions for a minimum of
3 months. Preliminary evaluation results with a sample of 95 parolees indicated
that during a 12-month follow-up, recidivism rates are comparable to those seen
in more intensive treatment; 48% had no new convictions, suspensions, or
revocations (Lightfoot, 1999).
Project MATCH (1998) studied whether different types of alcoholics (not
necessarily offenders) respond differently to particular treatments. There were
1,726 patients recruited from treatment facilities across the country were divided
into an outpatient group (recruited directly from the community) and an aftercare
group (just completed an inpatient or intensive day hospital treatment.
Participants in both groups were interviewed and tested to assess 20 individual
characteristics. Participants were randomly assigned to one of three treatments:
12 Step Facilitation, Cognitive Behavior Therapy, and Motivational Enhancement
Therapy. In a 36-month follow-up, the three treatments were found to be about
equally effective in terms of reducing drinking. Participants averaged 25 drinking
days per month before treatment and decreased to six drinking days per month
after treatment; they reported less drug use, less experience of depression, and
their liver function improved. Four participant characteristics were related to
successful treatment matching: anger, psychiatric severity, anger, and support of
drinking (Project Match Research Group, 1998).
Faye Taxman (1998) presented a paper on the reduction of recidivism through a
seamless community system of care at a conference sponsored by the Office of
National Drug Control Policy. Taxman evaluated twelve jurisdictions that
participated in the High Intensity Drug Trafficking Area project (HIDTA), funded
by the Office of National Drug Control Policy. Based on this research, Taxman
advocates moving from an individual case management approach to a systemic
case management approach which focuses on resource development, social
action plans, policy formation, data collection, information management,
program evaluation, and quality assurance. This approach integrates traditional
case management functions within the roles and responsibilities of appropriate
treatment and criminal justice staff. Twelve jurisdictions participated in the
HIDTA project, with the purpose of developing a seamless system between
criminal justice and treatment agencies by providing a continuum of treatment
care for the target population, drug testing and monitoring, and implementing
graduated sanctions to increase compliance with treatment. The study showed
14
that 72% of offenders completed the first phase of treatment and 62% continued
treatment in the second phase. The researchers found that 12% of the
offenders were arrested for new crimes during 9 months in the community. This
is a lower rate than expected based on the history of the clients.
In an article on substance abuse and restorative justice practices, Schwebel and
Zaslaw (2002) describes a cognitively based substance abuse program for
adolescents called Seven Challenges. This program, used both in the
community and institutional settings in Florida. The Seven Challenges Program
is philosophically compatible with restorative justice – helping young people to
examine their behavior and make good decisions. It is an experiential program
that uses cognitive behavioral activities such as role-playing, active discussion,
work books and, exercises relevant to young people. Ancillary treatment
includes social skill development, cognitive processing, anger management,
problem-solving techniques, and pre-vocational and vocational training. In a
study by Arizona State University researchers in 1999, Schwebel states that the
outcomes for the 83 males and females who participated in an intensive Seven
Challenges outpatient program were positive. There were statistically significant
reductions in drug use and criminal behavior and improvements in family
relationships.
Breaking the Cycle (Kennedy, 1999) is a project begun in 1996 with funding from
Office of National Drug Control Policy and the National Institute of Justice. There
are four sites: Birmingham, Alabama; Jacksonville, Florida; Tacoma,
Washington; and Eugene, Oregon. This initiative is a systemic intervention
strategy to identify, supervise and treat drug users in the criminal justice or
juvenile justice system. The Breaking the Cycle (BTC) model creates a system
of integrated testing, treatment and graduated responses, and supervision to
reduce drug use and recidivism in the offender population. The goal of the
program is to identify offenders at the point of arrest and begin treatment
services in jail that continue into the community, whether the offender is on
probation supervision or not. Treatment is provided based on clinical
assessments of problem severity. Drug treatment is paired with enforced
abstinence which is monitored through regular drug testing linked to specific
sanctions for continued drug use. The key components of BTC are early
intervention, judicial oversight, graduated sanctions, and collaboration between
justice and treatment agencies. The Urban Institute conducted a process
evaluation of the projects and an impact evaluation is under publication. A
preliminary report of Jacksonville’s BTC program found reductions in criminal
activity and drug use among drug-involved defendants based on surveys
conducted with felony defendants shortly after arrest and again nine months
later. The responses of a sample of BTC defendants were compared to a
sample of similar defendants arrested in the year before BTC was implemented
(Harrell, 2001).
15
Listwan et al., (2002) summarized the research on drug courts from the 1997
U.S. General Accounting Office (GAO) report. Drug courts developed in the
1990’s as an alternative to incarceration and a supplement to community
supervision. Today, almost every state in the United States has a drug court,
though they differ from jurisdiction to jurisdiction. Drug courts are judicially-based
interventions in which offenders are required to participate in substance abuse
treatment, drug testing, and in some cases comply with the conditions of
probation. A team approach is used to manage the offender’s case and frequent
court appearances are held so that the judge can assess progress and provide
rewards or sanctions based on treatment participation and compliance with court
requirements.
According to Listwan et al., (2002), the GAO report and other updated reviews of
the research conclude that drug courts are successful in reducing recidivism and
substance abuse. However, some studies have found that drug courts failed to
reduce recidivism. The conflict in these findings is likely due to the differences in
programs from one jurisdiction to another. It is difficult to determine which
components or combination of features of the drug court model are most
important for determining success. Generally, the research suggests that drug
courts have been moderately successful at reducing drug use and recidivism
among offenders participating in programs. However, since most drug courts
contract with available service providers, the evaluations do not provide
information on which treatment models are most effective.
Transition From Prison to the Community
Research previously discussed in this report indicates that treatment in prison is
less likely to have a long-term impact if treatment and aftercare in the community
do not follow it up for a substantial period of time. Fields (1998) notes that there
is research on institution pre-release models of treatment that work, and on
community treatment models that work, but too little research on the process of
successful transition form the institution to the community. The transition for
offenders who have been in treatment in prison to successful living in the
community is crucial and difficult.
Vaillant (1988) conducted a long term study of 100 hospital-treated heroin
addicts and 100 hospital-treated alcohol-dependent individuals. The two groups
were prospectively followed for 20 and 12 years respectively. The individuals in
the study were followed up every 18 months, and criminal and hospital records
were checked. Vaillant examined factors that contributed to relapse and freedom
from relapse. He found that relapse is usually the result of poorly patterned social
behavior and thus to avoid relapse, these individuals needed to alter their whole
pattern of living. For both groups, encountering one or more of the following –
community compulsory parole supervision, methadone maintenance, a substitute
dependence (e.g. meditation, compulsive gambling, overeating), new social
support relationships (e.g. employment, new marriage), and inspirational group
16
membership (e.g. fundamentalist religion, Alcoholics Anonymous) - appeared
associated with freedom from relapse. Long term structure in an addict’s life
when he or she is released to the community can interfere with drug-seeking
behavior and prevent relapse.
Fields (1998) describes a 1990 Oregon Department of Corrections project to
show the effects of a structured transition program from institution to community
treatment. Inmates are treated for 3-6 months in prison and then followed
intensively for 6-9 months in community treatment and supervision. Key program
elements include the following:
• Service providers “reach in” to the institution – Parole and drug treatment
services begin in prison several months before the release.
• Joint institutional/community-release planning – Prison staff developed
release plans with inmates, their parole officers, and drug treatment
coordinators.
• Intensive supervision – Once released, the offender is supervised on
intensive parole.
• Continuity of treatment – Group treatment is continued in the community,
often with members of the offender’s prison treatment group. Peer support
for abstinence and recovery is an important part of these groups.
• Careful management of incentives and sanctions – Offenders are offered
incentives for treatment participation in prison and in the community (e.g.
desirable housing, earn extra pass time, were provided special job skills
counseling). They lost privileges according to a graduated scale if they did
not cooperate in treatment. In the community, graduated sanctions were
applied as needed and incentives included assistance in housing,
employment, and other specialized services.
Outcome studies showed a drop in the arrest and conviction rates of participating
offenders during the year following treatment. There was also improvement in
employment and community adjustment.
Best Practices
National Institute on Drug Abuse
The National Institute on Drug Abuse (NIDA) compiled a booklet in 1999 that
outlines principles of effective treatment, both in the community and in the
institutional setting. This document is based on review of several studies and
meta-analyses. NIDA identified the following thirteen principles of effective
treatment:
1. There is no single treatment modality that is appropriate for everyone.
Treatment settings, interventions, and services should be matched to each
person's particular problems and needs.
2. Treatment needs to be readily available and accessible so that willing
persons can participate.
17
3. Effective treatment addresses the multiple needs of the individual, the drug
use and any associated medical, psychological, social, vocational, and legal
problems.
4. An individual's treatment and services plan must be assessed continually
and modified as necessary to ensure that the plan meets the person's
changing needs.
5. Remaining in treatment for an adequate period of time is critical for
treatment effectiveness. Research indicates that for most patients, the
threshold of significant improvement is reached at about 3 months in
treatment.
6. Counseling (individual and/or group) and other behavioral therapies are
critical components of effective treatment for addiction.
7. Medications are an important element of treatment for many patients, but
only when combined with counseling and other behavioral therapies. For
patients with mental disorders, both behavioral treatments and medications
can be critically important.
8. Addicted or drug-abusing individuals with coexisting mental disorders
should have both disorders treated in an integrated way. Offenders
presenting for either condition should be assessed and treated for the co-occurrence
of the other type of disorder.
9. Medical detoxification is only the first stage of addiction treatment and by
itself does little to change long-term drug use. This is also true for
abstinence.
10. Treatment does not need to be voluntary to be effective. Strong motivation
can facilitate the treatment process. Sanctions and enticements (family and
employment, for example) can increase treatment entry, retention, and the
success of drug treatment.
11. Possible drug use during treatment must be monitored continuously. The
monitoring of drug and alcohol use during treatment can help the patient
withstand urges to use drugs and also provide early evidence of drug use so
that the individual's treatment plan can be adjusted.
12. Treatment programs should assess for HIV/AIDS, hepatitis B and C,
tuberculosis and other infectious diseases, and provide counseling to help
patients modify or change high-risk behaviors.
13. Recovery from drug addiction can be a long-term process and frequently
requires multiple episodes of treatment. As with other chronic illnesses,
relapses to drug use can occur during or after successful treatment
episodes. Participation in self-help support programs during and following
treatment often is helpful in maintaining abstinence.
NIDA also published the following four findings specific to prison-based
treatment:
1) The therapeutic community model of treatment can be highly effective
in reducing drug use and recidivism.
2) Treatment participants should be segregated from the general prison
population to protect them from “prison culture.”
18
3) Treatment gains can be lost if inmates are returned to the general
population after treatment; this suggests that treatment, to be most
effective, should occur late in the incarceration.
4) Relapse and recidivism are significantly lower if inmates continue with
treatment in the community following release.
Etheridge, Rounds-Bryant, Hubbard Research
A research project by Etheridge and Hubbard, designed to collect outcome
measures for community-based treatment services, yielded a table of core
components and comprehensive services necessary for effective, holistic
treatment.
Substance Abuse Treatment:
Core Components and Comprehensive Services
Core Treatment Components Comprehensive Services
Intake processing/client assessment
Treatment plan
Abstinence-oriented counseling
Supportive group & individual
Counseling
Substance use/urine screening
Clinical & case management
Pharmacotherapy
Discharge plan
Aftercare/continuing care
Self-help/mutual help meetings
(AA/NA)
Medical Services
Mental health services
Housing
Transportation
Child care
Family services
Financial services
Legal services
HIV/AIDS risk services
Educational services
Vocational services
In an evaluation of North Carolina’s SARGE program, Rounds-Bryant, Etheridge,
and Hubbard cite several studies that demonstrate that superior outcomes are
achieved when inmates complete all phases of planned treatment, including
aftercare. They identified thirteen elements present in in-prison treatment
programs that effectively reduce recidivism:
• a comprehensive, intensive therapeutic approach aimed at the criminal and
substance using lifestyle rather than a focus on substance abuse alone
• programs having a clear and consistent treatment philosophy
• a program environment characterized by empathy and security
• a committed and qualified treatment staff
• clear and unambiguous rules of conduct
• the use of ex-addicts and ex-offenders as role models
• use of peer pressure and peer role models
• inclusion of self-help principles
• incorporation of relapse prevention
• aftercare/continuity of care during the post-release period
19
• adequate administrative support from correctional staff
• separation of treatment participants from general prison population
• a treatment model with an integrated evaluation component
Additionally, Rounds-Bryant, et al., offered guidelines for program development
based on these components:
• valid standardized assessments designed to identify multiple disorders that
are often present in incarcerated populations
• individualized treatment plans and treatment matching based on intensity
and service needs
• an array of treatment alternatives including cognitive-behavioral, social
learning, self-help, and therapeutic community approaches that address the
dual problems of substance abuse and criminal thinking and values
• random urine screening during treatment
• use of peer pressure and peer role models
High Intensity Drug Trafficking Study
Based on the results of a study of12 jurisdictions in the High Intensity Drug
Trafficking Area project, Taxman (1998) recommends 12 principles for effective
systems of treatment, supervision, and transition services in the community.
These principles are:
1. Recidivism reduction should be the goal of the criminal justice and treatment
system. This shared goal would bring the systems into alignment. It
requires each system to rethink operations and priorities and to jointly
reallocate resources.
2. Treatment and criminal justice system features must be policy driven. The
systems must develop integrated screening, placement, testing, monitoring,
and sanction policies. They must form a policy team to develop these joint
policies.
3. Treatment and criminal justice must function as a team. After policies are
developed, team members must put them into practice on an on-going daily
basis.
4. Use drug testing to manage offenders. Urinalysis allows for immediate
confirmation of an offender’s drug use. It is a tool for screening, treatment
matching and monitoring compliance. Joint policies on drug testing are
crucial.
5. Target offenders for treatment where treatment can “work.” Target high risk,
high need offenders, because treatment is more likely to have an effect on
this population and on crime
6. Use treatment matching practices. Use screening and assessment
information to make informed decisions about the type of offender who
should be placed in residential, intensive outpatient, and outpatient
programs. The American Society of Addiction Medicine (ASAM) has
developed a protocol for treatment placement.
20
7. Create a treatment process and extend the length of time in treatment.
Research affirms the importance of length of time in treatment for substance
abusers, with better results usually occurring from longer participation in
treatment programs. Add less intensive outpatient service to residential
services upon release.
8. Allow behavioral contracts to bind the offender, the treatment system and
the criminal justice system. A behavioral contract can specify the
expectations for the offender, treatment staff, and criminal justice staff. It is
an explicit set of expectations with rewards and sanctions for compliance.
9. Designate special agents for supervising offenders in treatment programs.
Train specialized probation officers to supervise offenders in treatment
programs. In order to have a close working relationship, both probation and
treatment staff need to be specialists.
10. Sanction non-compliant behavior. Use contingency management, token
economies, and behavior modification techniques to address compliance.
Use sanctions to hold offenders accountable under their behavioral contract.
11. Reward positive behavior. The criminal justice system does not often
acknowledge positive achievements made by offenders. Yet an incentive
system that is swift, certain, and progressive can increase positive behavior.
12. Focus on quality, not quantity. Don’t lose sight of the goal, to reduce
recidivism. Instead of trying to serve the maximum number of offenders, try
to serve fewer offenders better in order to produce intended outcomes.
Don’t provide cheap services if they don’t work, provide services that work,
even if they are more costly.
Taxman concludes by saying that effective treatment services are synonymous
with effective criminal justice services.
21
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